Aging Clinical and Experimental Research (2021) 33:1353–1358

https://doi.org/10.1007/s40520-020-01671-4

ORIGINAL ARTICLE

EWHETA (Eat Well for a HEalthy Third Age) Project: novel foods
to improve the nutrition in the elderly people
R. Volpe1 · S. Predieri2 · M. Cianciabella2 · G. M. Daniele2 · E. Gatti2 · M. Magli2 · P. Rodinò1 · E. Schiavetto1 ·
G. Sotis1 · S. Urbinati1

Received: 6 May 2020 / Accepted: 23 July 2020 / Published online: 7 August 2020
© Springer Nature Switzerland AG 2020

Abstract
Cardiovascular diseases (CVD) are the leading cause of mortality. However, by treating modifiable cardiovascular risk fac-
tors and following a healthy diet as the Mediterranean diet, we have opportunity to prevent CVD. In the EWHETA (Eat Well
for a HEalthy Third Age) Project, our goal has been to develop novel foods (“Mediterranean Lasagne”, MLs) in versions
all nutritionally complete and well balanced in terms of calories, whole carbohydrates, fibers, source of vegetable proteins,
and vegetable fats. MLs can be easy prepared at home (inexpensively) and used as fresh food or can be pre-prepared and
used in residences for elderly people or in health care residencies. The project has saw the alliance between nutritionists
and food and sensor scientists and the active involvement of older people in tasting the novel foods to achieve the final tasty
versions of the MLs. We think that the nutritional components of these novel foods and its well-accepted taste, insert in a
healthy diet and life style (fundamental aspects at every age), and could contribute to improve diet in the elderly people and
prevent malnutrition.

Keywords Novel foods · Nutrition · Alliances · Elderly people

Introduction above all of the “Mediterranean” diet (MD), a dietary regime

associated with lower cardiovascular risk and lower total
Cardiovascular diseases (CVD) are the leading cause of mor- mortality [4, 5]. This diet is low in saturated fatty acids and
tality [1]. However, by treating modifiable cardiovascular cholesterol, and rich in monounsaturated fatty acids (found
risk factors, we have opportunity to prevent CVD. In agree- in extra-virgin olive oil), in omega-3 fatty acids (found in
ment with Hippocrates (“If nutrition and physical activity fish and nuts), in whole grains with a low glycaemic index,
are inadequate, the body gets sick”), un-healthy diet is for in fibers, in vegetable proteins (more than animal proteins),
itself a risk factor for CVD and a contributor to the devel- and in antioxidants, such as vitamins and polyphenols [6].
opment of cardiovascular risk factors. It also may increase Mono-unsaturated fatty acids and omega-3, in particular,
the incidence of other non-communicable-diseases such maintain also the structure of neural cells, while antioxi-
as osteoporosis, neurodegenerative diseases [2] and some dants play a significant role in the prevention or attenuation
type of cancer [3]. On the contrary, a well-balanced diet can of pathologies associated with redox imbalance (oxidative
reduce the risk of developing type 2 diabetes, CVD, several damage and inflammation), such as atherosclerosis and other
type of cancers, Parkinson’s disease, and Alzheimer‘s dis- chronic degenerative diseases [7, 8]. In other words, the MD
ease [4, 5]. When we talk of a healthy diet, we are talking contains a large number of “functional foods” thanks to its
substances which provide health benefits also in elderly peo-
ple [9, 10]. Therefore, through proper nutrition (and regular
* R. Volpe moderate physical activity and not smoking), we can not
[email protected] only prevent CVD and increase life expectancy, but also
* S. Predieri maintain a physical and mental health.
[email protected] However, aging is often accompanied by changes in food
1
Servizio Prevenzione e Protezione, SPP-CNR, Rome, Italy consumption, either voluntary or more often due health
2 issues [11], by isolation and depression or by alterations in
Istituto di BioEconomia IBE-CNR, Bologna, Italy

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1354 Aging Clinical and Experimental Research (2021) 33:1353–1358

sensory sensitivity [12], which affect taste and smell and men, 49% women) was involved also in practical sensory
food choices [13]. This may lead to disaffection for eating and hedonic tests, conducted in the canteen of the same
and inappropriate food behaviors that may lead to malnutri- clubhouses.
tion, accelerating the aging process and increasing the risk
of disease and mortality [14].
Instead, a good protein intake could help to maintain Eating tests
a healthy weight and to preserve muscle mass preventing
frailty and the diseases and mortality associated with it [15].
However, not all proteins are the same: if there is a correla- (1) Dressed pasta ranking test
tion between animal-based protein intake and CVD inci-
dence, there is an inverse correlation between plant-based Participants were selected for conducting a hedonic test on
protein intake and CVD incidence [16]. sauces, differing for fat or proteic ingredients, used to dress
Another important aspect is that if food education may typical Italian pasta (“Garganelli” and “Strozzapreti”). A
be effective for promoting adequate eating behavior also in first test proposed the original “Ragù alla Bolognese” rec-
older people, where the role of an appealing and enjoyable ipe (A) with standard beef meat (10% fat), (B) with low
food is very important, because has been reported a loss fat beef meat, (C) with low fat beef meat plus extra-virgin
of sensitivity for bitter and reduced smell acuity [17–20]. olive oil (EVOO). A further test proposed a “Courgettes
About that sensory sciences can provide methods for inves- sauce”, (D) added with low fat beef meat (E) with peas, and
tigating senior consumers’ attitudes and preferences, and can (F) with chicken meat. Participants were request to order
support the creation of satisfactory and palatable foods for dishes according to their preference [21], from the best to
the elderly people [17–20]. the worse, and to express an hedonic evaluation from 1 (I do
not like at all) to 9 (like extremely) [22];

Aim of the study (2) Individual sensitivity to bitter and EVOO evaluation

In the EWHETA (Eat Well for a HEalthy Third Age) Project, Participants were involved in sensory and hedonic tests with
our goal has been to develop novel foods (“Mediterranean EVOO with different polyphenol content. Since polyphenols
Lasagne”) (ML) not only nutritionally complete and well give to EVOO its bitter taste, as a first step, participants were
balanced in terms of calories, whole carbohydrates, fibers, subjected to a 6-n-propylthiouracil (PROP) test to assess
vegetable proteins, vegetable fats, and salt, but also easy to sensitivity to bitter [19, 20]. According to the protocol
prepare at home (the ingredients are simple, easy to buy and applied for assessing bitter sensitivity [23], subjects were
not expensive), easy to heat up, easy to chew and swallow instructed to hold a diluted PROP sample in their mouth for
(even if there are difficulties of mastication due to dental 10 s (s), then expectorate, wait 20 s, and evaluate the inten-
problems), and tasty. To improve the sensorial features, we sity of bitterness using a general Labeled Magnitude Scale
went through an active involvement of older people, which (gLMS) [24]. To test preference, two EVOOs with different
tested and judged the novel foods, to achieve the final tasty polyphenols’ content (high, HP 400 mg/kg, and very high,
versions. VHP, 1000 mg/kg) were evaluated on a slice of bread. Sub-
jects evaluated the two EVOOs through the “Two-alternative
forced choice (2AFC) sensory tests”, adapted to cognitive
Methods capacities of participants. Participants received two sam-
ples of bread with both EVOOs (HP and VHP), and were
To recruit aged people, living independently and autono- requested to taste both sample and to place the preferred into
mous is food choice, and seminars on food education and a dish labeled as “Migliore” (the best);
health were organized in two Italian Regions (Emilia-
Romagna and Lazio), in senior citizen clubhouses. Elderly (3) Evaluation of individual smell acuity.
people (170 persons, 55% men, 45% women over 65 years
old, average 73 years old), were, contacted in two sites in Smell acuity is reported to be quite reduced by aging as
Northern Italy (Bologna) and in Center of Italy (Rome). a physiological effect [25, 26]. Participants were submit-
Prior to a direct involvement in eating tests, participants ted to a smell-cognitive validated test by asking to identify
were requested to contribute to a survey about present and odors (mint, pine, banana, and anise) and to indicate the rela-
past food habits, and to express their preferences about the tive intensity [23]. The odors were selected from the ones
development of healthy recipes based on the first courses included in the European Test of Olfactory Capabilities and
with sauces [18]. A selection of the participants (68: 51% presented using cardstocks;

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(4) ML with protein sources alternative to red meat. The test conducted on sensitivity to bitter based on PROP
test showed males to be considerably less sensitive to bitter
In a preliminary test participants tested 6 sauces, contain- than females, with a loss of perception versus a younger
ing 3 protein sources alternative to red meat (chicken meat, cohort (Table 2). On the contrary, the elderly females
lentils, and squid + cod). On the basis of the results, fish and showed an increased sensitivity to bitter versus a younger
lentils were chosen as MLs’ filling sauces. Four MLs’ types population.
were prepared for hedonic test: (a) fish with HP EVOO, (b)
fish with VHP EVOO, (c) lentils with HP EVOO, and (d) When HP and VHP EVOOs were proposed on a bread slice,
lentils with VHP EVOO. VHP EVOO was preferred only by 18% participants, indi-
Statistical comparisons of percentages were made by cating that the bitter taste was not really appreciated. No
Pearson Chi square analysis (*p < 0.05). Means were ana- correlation was found with sensitivity to PROP, suggesting
lyzed with ANOVA. The SAS/STAT statistical software that not only bitterness, but also other sensory traits of VHP
package version 9.4 (SAS Institute Inc., Cary, USA) was EVOOs, such as pungency, may influence liking.
used for the data analysis.
(3) Evaluation of individual smell acuity

Results The test conducted to evaluate the ability of correctly iden-

tify odors showed that nearly 90% of the older people could
identify mint odor (Table 3). On the contrary, the other
(1) Dressed pasta ranking test odors were identified by about only 60% of the participants.

“Ragù alla Bolognese” (Bolognese sauce) recipe A with

standard beef meat (10% fat) was chosen as the first choice
by 45% of participants, recording the highest liking score. Table 2  Intensity rating expressed by older people involved in
EWHeTA project versus younger people involved in the Italian Taste
The sauces B, with low fat beef meat, and C with the addi- Project
tion of EVOO, had similar results in terms of preference.
Gender Bitter intensity ratings gLM Bitter intensity
The test proposing different type of “Courgettes sauce”,
Scale in eldely people (> 65 years ratings gLM
showed as the most preferred addition was the source with old, male versus female) Scale in young-
low fat meat, but the use of lentils recorded the same perfor- adult people
mance in ranking, since the lowest percentage of participants (20–60 years
old, male versus
placed it at the last place (Table 1). Median indicated that
female)
A and B recipes were the most appreciated. The courgettes
sauce with the addition of chicken meat recorded the lowest Male 29.8 39.8
level of acceptability, with 25% of the participants providing Female 55.2 (*vs male) 44.9
liking score below the minimum threshold. Total 41.8 42.8

Bitter intensity perception comparison between men and women of

(2) Individual sensitivity to bitter and EVOO evaluation same age range, and for total population involved were analyzed with
ANOVA. *p < 0.05

Table 1  Evaluation of pasta sauces differing in fat and protein source

Pasta sauce Fat and proteins First choice Last choice Liking score Liking score Accepta-
% % Mean Median bility
%

Meat sauce (bolognese souce) (A) StanFdard beef meat 45* 25 6.93* 7 97
(B) Low-fat beef meat 28 36 6.62* 7 79
(C) Low-fat beef meat + EVOO 27* 39 6.31* 6 93
Vegetable sauce (courgettes sauce) (D) Fish 46* 33 6.52* 6 86
(E) Lentils 36 21 6.31* 6 96
(F) Chicken meat 18* 46 5.97* 6 75

Percentage of first and last choice, liking score (1: do not like at all; 5: acceptability level; 9: like extremely) mean, median and percentage of
acceptability (score ≥ 5). Statistical comparisons of First-Choice/Last-Choice, percentages were made by Pearson χ2-analysis (*p < 0.05). Liking
score means were analyzed with ANOVA

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Table 3  Odor identification by older people involved in EWHeTA and with higher acceptability) (Table 4). Lentils filled lasa-
project (left) versus younger people involved in the Italian Taste Pro- gna were the first choice for only 35% of participants (with
ject (right)
the ML with HP EVOO chosen more frequently). Versus a
Odor Odor identification (%) in Odor identification (%) in traditional lasagna, the MLs provide less calories, which
elderly people (> 65 years young-adult people (20–60 contain much less total fats and saturated fats with a better
old) years old)
proportion of monounsaturated and polyunsaturated fats,
Mint 87.7 98.9 many more carbohydrates for the lentils lasagna (while the
Pine 62.5 86.9* fish lasagna it contains less), many more fibers for the lentils
Banana 62.5 89.1* lasagna (while the fish lasagna slightly less), and much less
Anise 60.9 77.6* salt for the lentils lasagna (while the fish lasagna slightly
more). For protein, the differences were little (slightly less
*p <0.05
protein for the MLs) (Table 5).

Table 4  Evaluation of lasagna filled with either fish or lentils, added

of EVOO with high (HP) or very high (VHP) polyphenols content Discussion
Lasagna Type of First choice % Average Accept-
filling EVOO liking ability % The important role of healthy life style in the prevention of
score disability and death in the elderly people is a well-recog-
Squid + fish HP 29 6.7* 79 nized care. Therefore, a diet that adhere to healthy eating
VHP 36 6.7* 90 guidelines can postpone morbidity and mortality from CVD.
Total 65* Mediterranean diet has showed a great and positive impact
Lentils HP 21 6.7* 86 on health and diseases, also in elderly people [9, 10]. Beside
VHP 14 6.3* 81 the individual motivations for choosing food good for health,
Total 35 eating pleasure is a fundamental element for supporting a
long-lasting healthy food behavior [27, 28]. In the EWHETA
Percentage of first choice, acceptability (liking score ≥5) and average Project, a group of elderly people were actively involved in
liking score. Statistical comparisons of first choice/last choice, per-
centage were made by Pearson χ2-analysis (*p <0.05). Liking score
the steps for the creation of novel foods, the MLs. Eating
means were analyzed with ANOVA. *p <0.05 tests were applied to assess individual sensitivity to bitter
and smell acuity to identify odors. To have the response of
a panel of elderly assessors is substantial, since their percep-
Moreover, the performance resulted poorer versus that tions may differ from those of younger adults [29, 30]. In our
recorded in a younger population. group, the results obtained on sensitivity to bitter showed
only for male the expected loss acuity [31], while female
(4) ML with protein sources alternative to red meat. showed an opposite trend, suggesting a sensitivity to bitter
even increasing with age. Also the study on taste has showed
The four MLs were prepared: (a) with fish and HP EVOO, a loss of sensitivity more intense for males then females
(b) with fish and VHP EVOO, (c) with lentils and HP [31] and the test on smell has indicated the expected loss of
EVOO, and (d) with lentils and VHP EVOO received posi- sensitivity [32]. However, the recorded good percentages of
tive liking scores and elevated acceptability. However, MLs correct identification indicated a basic ability, very useful
with fish were chosen as “the best” (first choice) by 65 of for being applied for food choice in an age where often the
the consumers (with ML with VHP chosen more frequently people eat less, enjoy the food less, and have problems with

Table 5  Nutrition composition for 100 g (1 portion = 240 g) of traditional lasagna (with beef meet) and “Mediterranean lasagna” with lentils
and fish
Kcal Total fat (g) SF (g) MUFA (g) PUFA (g) Carbo (g) Fibers (g) Protein (g) Na (mg)

Beef ­meeta 198 10.8 5.8 4.2 0.8 13.4 0.8 11.7 373
Fish 123 7.3 1.0 3.6 2.7 4.1 0.7 10.2 388
Lentils 172 7.1 1.0 4.7 1.4 19.1 4.6 8.0 292

SF saturated fat, MUFA monounsaturated fat, PUFA polyunsaturated fat, carbo carbohydrates, Na sodium
a
CREA, AlimentiNUTrizione, Tabelle composizioni alimenti 2019 https​://www.alime​ntinu​trizi​one.it/il-porta​le; USDA Department of Agricul-
ture, Agricultural Research Service 2011

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chewing or swallowing and/or digestion, important causes of in understanding (and judging) nutritional information, a
malnutrition, and, eventually, frailty and sarcopenia. crucial measure to promote healthier food choices. The idea
Thanks to the contribution of elderly assessors, it was was to promote also and above all healthy eating that became
possible to create different types of MLs, filled with chicken, a tool in an integrated nutrition education project.
fish, or legumes, as protein sources alternative to red meat.
The modification of the original “Ragù alla Bolognese”
(Bolognese souce) recipe (based on fatty red meat) was
Conclusions
well accepted by assessors and positively evaluated, except
lasagna filled with chicken meat being not an appreciated
As nutritionists, we need to address the barriers that hin-
protein source.
der healthy eating in elderly people and identify the fac-
As the traditional lasagna, the MLs are nutritionally com-
tors facilitating healthy food consumption as, for exam-
plete which, however, seem better balanced: provide less cal-
ple, to prepare new cost-effective meals that meet dietary
ories (and fish lasagna much less), and contain less total fats
recommendations.
and saturated fats with a better proportion of monounsatu-
In the EWHETA Project, our goal has been to develop
rated and polyunsaturated fats, many more carbohydrates for
novel foods (“Mediterranean Lasagne”) according to recipes
the lentils lasagna (while the fish lasagna it contains less),
which nutritionally complete and well balanced to cover the
many more fibers for the lentils lasagna (while the fish lasa-
majority of nutritional requirements and caloric needs, but
gna slightly less), and much less salt for the lentils lasagna
also tasty (as shown by our tests on palatability and accept-
(while the fish lasagna slightly more). In other words, the
ability performed thanks to the active involvement of older
MLs contain substances which provide health benefits also
people in tasting the novel foods). MLs can be easy prepared
in elderly people, and the lentils lasagna, thanks to the high
at home (inexpensively) and used as fresh food or can be
content in fibers and low in salt, could be helpful for elderly
pre-prepared and used in residences for elderly people or in
with diabetes and, respectively, arterial hypertension and/or
health care residencies.
heart failure. For protein, the differences were little (slightly
We think that this approach, reinforced through seminars
less protein for the MLs).
in nutrition, could contribute to improve diet in the elderly
EVOO with a VHP content was not appreciated by itself,
people and prevent malnutrition. Indeed, if is true that the
but contributed to the appreciation of fish-based lasagna.
increase in life expectancy often means more years but with
These results show how not just the ingredients, but also the
illness and disability [38], on the contrary, we believe that,
specific use of its, are effective in determining food apprecia-
with several contributions and several actions, everyone can
tion, above all in older people where the role of an appeal-
help to achieve a better health also in elderly people [8].
ing and enjoyable food is very important, because has been
reported a loss of sensitivity for bitter and reduced smell
acuity [25, 26, 29–34]. Funding The work was carried out with the financial support of the
About bitter, the subgroup analysis of the PREDIMED Project “EWHeTA” in the framework of the Italian National Project
trial revealed that the higher polyphenol contents (gives bit- “Aging”—MIUR (Ministry of Instruction, Research, University) and
CNR-DISBA project NutrAge (project nr. 7022).
terness to the foods) and intake are associated with lower
incidence of the primary outcome, overall mortality, blood
pressure, inflammatory biomarkers, onset of new-onset type Compliance with ethical standards
2 diabetes mellitus, and obesity [35, 36]. In addition to poly-
Conflict of interest On behalf the other authors, the corresponding au-
phenols, however, the MD is also very rich in unsaturated thors state that there is no conflict of interest.
fatty acids (UFA) and it has been increasingly recognized
that a diet high in UFA is extremely important for CV health. Statement of human and animal rights All human and animal rights
have been respected.
Food rich in UFA is often also rich in polyphenols (i.e.,
EVOO): it is possible that a combination of the polyphenols Informed consent For this type of study, formal consent is not required.
and UFA could produce a beneficial effect on CV health and
overall health of elderly persons [35, 36].
Finally, as observed in the previous studies [37], elderly
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